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Elderly Drivers with Cognitive Impairment

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181. Geriatric Rehabilitation (Treatment)

in the older population if a functional loss of mobility and an inability to perform activities of daily living (ADLs) predominates. [ ] Cognitive impairment, such as delirium and dementia, can affect the patient's rehabilitation goals and outcomes. Finally, a driver's evaluation for an appropriate elderly candidate is an underutilized part of rehabilitation that has a considerable impact on society. See the images below. Driver's evaluation. Steps in testing for reaction time. Driver's evaluation (...) of 65 years has significant hearing loss is 25-50%. The prevalence of hearing loss increases to 50% in people older than 75 years. The geriatric population is growing, and in the near future, the number of geriatric patients experiencing severe sensory loss is likely to increase. Poor vision, a high level of comorbidity, and depression are related to hearing loss in the elderly. Not all hearing impairments are reversible. Examples of impairments that are potentially reversible involve cerumen

2014 eMedicine.com

182. Obstructive Sleep Apnea (Follow-up)

and/or hypopnea, oxyhemoglobin desaturation, RERAs, and snoring from sleep. It also results in adequate sleep continuity. CPAP has been shown to improve daytime sleepiness, mood, and cognitive function in people with both mild and moderate apnea. [ , ] CPAP has also been shown to decrease blood pressure, primarily in patients with severe OSA. [ , , ] Evidence also indicates that it may improve the left ventricular ejection fraction in patients with congestive heart failure and OSA. [ ] CPAP plus (...) adherent patients should be asked about mask fit, mask leak, sinus/nasal congestion, mouth breathing, and general sleep habits to determine reasons for nonadherence. Interventions to improve compliance include (1) attendance in a group clinic with education provided, (2) group cognitive behavioral therapy provided as two 1-hour sessions that include an educational talk and video of real CPAP users, (3) written literature and weekly phone calls during the first month of use, (4) use of nasal

2014 eMedicine.com

183. Obstructive Sleep Apnea-Hypopnea Syndrome (Follow-up)

and/or hypopnea, oxyhemoglobin desaturation, RERAs, and snoring from sleep. It also results in adequate sleep continuity. CPAP has been shown to improve daytime sleepiness, mood, and cognitive function in people with both mild and moderate apnea. [ , ] CPAP has also been shown to decrease blood pressure, primarily in patients with severe OSA. [ , , ] Evidence also indicates that it may improve the left ventricular ejection fraction in patients with congestive heart failure and OSA. [ ] CPAP plus (...) adherent patients should be asked about mask fit, mask leak, sinus/nasal congestion, mouth breathing, and general sleep habits to determine reasons for nonadherence. Interventions to improve compliance include (1) attendance in a group clinic with education provided, (2) group cognitive behavioral therapy provided as two 1-hour sessions that include an educational talk and video of real CPAP users, (3) written literature and weekly phone calls during the first month of use, (4) use of nasal

2014 eMedicine.com

184. Rhinitis, Allergic (Follow-up)

Workshop Group., World Health Organization. Allergic rhinitis and its impact on asthma. J Allergy Clin Immunol . 2001 Nov. 108 (5 Suppl):S147-334. . Banov CH, Lieberman P,. Efficacy of azelastine nasal spray in the treatment of vasomotor (perennial nonallergic) rhinitis. Ann Allergy Asthma Immunol . 2001 Jan. 86(1):28-35. . Colás C, Galera H, Añibarro B, Soler R, Navarro A, Jáuregui I, et al. Disease severity impairs sleep quality in allergic rhinitis (The SOMNIAAR study). Clin Exp Allergy . 2012 Jan (...) dependence and time course of the immunologic response to administration of standardized cat allergen extract. J Allergy Clin Immunol . 2004 Dec. 114(6):1339-44. . Bozek A, Ignasiak B, Filipowska B, Jarzab J. House dust mite sublingual immunotherapy: a double-blind, placebo-controlled study in elderly patients with allergic rhinitis. Clin Exp Allergy . 2013 Feb. 43(2):242-8. . Virchow JC, Backer V, Kuna P, Prieto L, Nolte H, Villesen HH, et al. Efficacy of a House Dust Mite Sublingual Allergen

2014 eMedicine.com

185. Pathophysiology of Chronic Back Pain (Follow-up)

intervertebral disk may impair the resolution of some persistent painful cases of chronic LBP (cLBP). An estimated 15-20% develop protracted pain, and approximately 2-8% have chronic pain. Of those individuals who remain disabled for more than 6 months, fewer than half return to work, and after 2 years of LBP disability, a return to work is even more unlikely. [ ] Studies suggest that one third to one fourth of patients in a primary care setting may still have problems after 1 year. [ , ] cLBP is the most (...) —a staggering 500,000 cases. LBP accounts for 19% of all workers' compensation claims in the United States. According to the Bureau of Labor and Statistics, metal workers generate 76% of all claims of back strain and/or sprains. Jobs that require heavy manual labor and material-handling activities account for more than half of all back pain reports. Injuries to the back are highest among truck drivers, operators of heavy equipment, and construction workers. From 1971-1981, the number of Americans disabled

2014 eMedicine.com

186. Insomnia (Follow-up)

include long-acting forms (eg, flurazepam, quazepam), intermediate-acting forms (eg, temazepam, estazolam), and short-acting forms (triazolam). The long-acting agents are rarely used today for insomnia because of daytime sedation, cognitive impairment, and increased risk of falls in elderly patients. Benzodiazepines were commonly used until the 1980s, when tolerance, dependence, and daytime side effects were recognized as major limitations of these agents, particularly those with long elimination half (...) enough to impair these activities. [ , ] Eszopiclone has a half-life of 5-7 hours and can be used for sleep-maintenance insomnia. The starting dose is 1 mg immediately before bedtime, with at least 7-8 hours remaining before the planned time of awakening. The dose may be increased if clinically warranted to 2-3 mg HS in nonelderly adults, and 2 mg in elderly or debilitated patients. Next-day impairment can occur after taking after a starting dose of 2 mg. FDA findings from observing 91 healthy adults

2014 eMedicine.com

187. Insomnia (Follow-up)

include long-acting forms (eg, flurazepam, quazepam), intermediate-acting forms (eg, temazepam, estazolam), and short-acting forms (triazolam). The long-acting agents are rarely used today for insomnia because of daytime sedation, cognitive impairment, and increased risk of falls in elderly patients. Benzodiazepines were commonly used until the 1980s, when tolerance, dependence, and daytime side effects were recognized as major limitations of these agents, particularly those with long elimination half (...) enough to impair these activities. [ , ] Eszopiclone has a half-life of 5-7 hours and can be used for sleep-maintenance insomnia. The starting dose is 1 mg immediately before bedtime, with at least 7-8 hours remaining before the planned time of awakening. The dose may be increased if clinically warranted to 2-3 mg HS in nonelderly adults, and 2 mg in elderly or debilitated patients. Next-day impairment can occur after taking after a starting dose of 2 mg. FDA findings from observing 91 healthy adults

2014 eMedicine.com

188. Cancer and Rehabilitation (Follow-up)

tumor progression and treatment causes a functional decline or when the disease causes a fluctuation in abilities, rehabilitation assumes a supportive role, and its goals are adjusted to accommodate the patient's persistent anatomic and physiologic limitation. Thorough assessment of cognitive dysfunction, physical impairments, disabilities, and handicaps is paramount before the team proceeds with rehabilitation. Emphasis is initially placed on restoring or maximizing independence with ADLs, mobility (...) , rehabilitation for cancer-related disability is an underutilized resource. [ , , ] Reasons for underutilization are multidimensional. Cancer-related symptoms often have gradual onset, and patients may be hesitant to tell their oncologist about issues such as deconditioning, poor balance, impaired mobility, pain, poor nutrition, decreased cognitive function, and altered self-image. [ , ] Furthermore, oncologists may not be in the habit of specifically asking about these impairments. Movsas et al confirmed

2014 eMedicine.com

189. Head Injury (Follow-up)

Mild head injuries are those that generate GCS scores of 13-15. Such injuries usually are considered relatively benign, and the accompanying cognitive impairments typically resolve within 3 months of injury. Patients with lingering complaints are often assumed to have either a psychological reaction to the injury or to be malingering. Various standardized neuropsychologic instruments are available to help sort out legitimate from illegitimate cognitive impairments. About 25% of patients with mild (...) disability, but all these patients also had either radiological abnormalities or focal neurological signs, placing them in the more severe range of mild head injuries. [ ] A recent review sponsored by the National Institute of Medicine concluded that there is no clear evidence of lasting cognitive impairments attributable to mild closed head injuries. [ ] Second impact syndrome In the United States, athletic competitions account for 300,000 mild head injuries per year. The second impact syndrome occurs

2014 eMedicine.com

190. Geriatric Rehabilitation (Follow-up)

in the older population if a functional loss of mobility and an inability to perform activities of daily living (ADLs) predominates. [ ] Cognitive impairment, such as delirium and dementia, can affect the patient's rehabilitation goals and outcomes. Finally, a driver's evaluation for an appropriate elderly candidate is an underutilized part of rehabilitation that has a considerable impact on society. See the images below. Driver's evaluation. Steps in testing for reaction time. Driver's evaluation (...) of 65 years has significant hearing loss is 25-50%. The prevalence of hearing loss increases to 50% in people older than 75 years. The geriatric population is growing, and in the near future, the number of geriatric patients experiencing severe sensory loss is likely to increase. Poor vision, a high level of comorbidity, and depression are related to hearing loss in the elderly. Not all hearing impairments are reversible. Examples of impairments that are potentially reversible involve cerumen

2014 eMedicine.com

191. Obstructive Sleep Apnea (Diagnosis)

quiet activities (eg, reading, watching television); as the severity worsens, patients begin to feel sleepy during activities that generally require alertness (eg, school, work, driving) Daytime fatigue/tiredness Cognitive deficits; memory and intellectual impairment (short-term memory, concentration) Decreased vigilance Morning confusion Personality and mood changes, including depression and anxiety Sexual dysfunction, including impotence and decreased libido Gastroesophageal reflux Hypertension (...) to diagnose OSA. Routine laboratory tests, however, are usually not helpful in OSA unless a specific indication is present. Pulmonary function tests are not indicated to make a diagnosis of, or treatment plan for, OSA alone. The standard indications for such testing apply to all patients, with or without OSA. Obtain a thyrotropin test on any patient with possible OSA who has other signs or symptoms of hypothyroidism, particularly in elderly individuals. AASM standards and guidelines for diagnostic

2014 eMedicine.com

192. Obstructive Sleep Apnea-Hypopnea Syndrome (Diagnosis)

quiet activities (eg, reading, watching television); as the severity worsens, patients begin to feel sleepy during activities that generally require alertness (eg, school, work, driving) Daytime fatigue/tiredness Cognitive deficits; memory and intellectual impairment (short-term memory, concentration) Decreased vigilance Morning confusion Personality and mood changes, including depression and anxiety Sexual dysfunction, including impotence and decreased libido Gastroesophageal reflux Hypertension (...) to diagnose OSA. Routine laboratory tests, however, are usually not helpful in OSA unless a specific indication is present. Pulmonary function tests are not indicated to make a diagnosis of, or treatment plan for, OSA alone. The standard indications for such testing apply to all patients, with or without OSA. Obtain a thyrotropin test on any patient with possible OSA who has other signs or symptoms of hypothyroidism, particularly in elderly individuals. AASM standards and guidelines for diagnostic

2014 eMedicine.com

193. Pathophysiology of Chronic Back Pain (Diagnosis)

intervertebral disk may impair the resolution of some persistent painful cases of chronic LBP (cLBP). An estimated 15-20% develop protracted pain, and approximately 2-8% have chronic pain. Of those individuals who remain disabled for more than 6 months, fewer than half return to work, and after 2 years of LBP disability, a return to work is even more unlikely. [ ] Studies suggest that one third to one fourth of patients in a primary care setting may still have problems after 1 year. [ , ] cLBP is the most (...) —a staggering 500,000 cases. LBP accounts for 19% of all workers' compensation claims in the United States. According to the Bureau of Labor and Statistics, metal workers generate 76% of all claims of back strain and/or sprains. Jobs that require heavy manual labor and material-handling activities account for more than half of all back pain reports. Injuries to the back are highest among truck drivers, operators of heavy equipment, and construction workers. From 1971-1981, the number of Americans disabled

2014 eMedicine.com

194. Head Injury (Diagnosis)

with longer durations of posttraumatic amnesia have poorer outcomes. [ ] In the long-term setting, the following bedside cognitive tests can be employed: Mini-Mental State Examination Luria "fist, chop, slap" sequencing task: To rapidly assess motor regulation Antisaccade task: Impaired in patients with symptomatic brain injury; the sensitivity of this test in detecting brain injury has been questioned [ ] Letter and category fluency: To provide information about self-generative frontal processes. Untimed (...) studies suggested that elevated serum levels may correlate with persistent cognitive impairment at 6 months in patients with severe or mild head injuries, current opinion considers these tests no longer useful. [ , ] In 2018, a commercially available blood test for mild brain injury was approved by the FDA. [ ] This test reportedly identifies 98% of patients with abnormal head CT scans. Imaging studies Computed tomography scanning: The main imaging modality used in the acute setting Magnetic resonance

2014 eMedicine.com

195. Assistive Devices to Improve Independence (Treatment)

. Depression is common in the older population if a functional loss of mobility and an inability to perform activities of daily living (ADLs) predominates. [ ] Cognitive impairment, such as delirium and dementia, can affect the patient's rehabilitation goals and outcomes. Finally, a driver's evaluation for an appropriate elderly candidate is an underutilized part of rehabilitation that has a considerable impact on society. See the images below. Driver's evaluation. Steps in testing for reaction time (...) that a patient over the age of 65 years has significant hearing loss is 25-50%. The prevalence of hearing loss increases to 50% in people older than 75 years. The geriatric population is growing, and in the near future, the number of geriatric patients experiencing severe sensory loss is likely to increase. Poor vision, a high level of comorbidity, and depression are related to hearing loss in the elderly. Not all hearing impairments are reversible. Examples of impairments that are potentially reversible

2014 eMedicine.com

196. Mirabegron (Myrbetriq)

satisfactory response. The 25 mg dose once daily will also be available for use in patients with moderate hepatic or severe renal impairment. The chemical name of mirabegron is 2-(2-aminothiazol-4-yl)-N-[4(2-{[(2R)-2-hydroxy-2- phenylethyl]amino}ethyl)phenyl]acetamide having an empirical formula of C21H24N4O2S and a molecular weight of 396.51. Figure 1: Mirabegron Molecule Source: Figure 21, Clinical Overview, page 15. Since the immediate release formulations or mirabegron showed a considerable decrease (...) with renal impairment were compared pharmacokinetically to healthy control volunteers who were matched for sex, age and weight. Following single dose administration of 100 mg mirabegron in volunteers with mild renal impairment (estimated glomerular filtration rate [eGFR] 60 to 89 mL/min/1.73 m2 as estimated using the Modification of Diet in Renal Disease [MDRD] equation), mean mirabegron C max and AUC inf were increased by 6% and 31% relative to volunteers with normal renal function. In volunteers

2012 FDA - Drug Approval Package

197. Jakavi - ruxolitinib

). Special populations The pharmacokinetics of ruxolitinib and metabolites have been studies under single-dose conditions in patients with normal, mild, moderate, severe or end-stage renal function impairment. Renal function was measured using Modification of Diet in Renal Disease (MDRD) as well as U-creatinine. As expected, the (total) exposure of ruxolitinib is not affected by renal impairment (mild to end stage renal disease- ESRD). However, the exposure of several metabolites is increased (...) metabolites) following multiple-dose administration of INCB018424 in patients with various degrees of renal impairment (ESRD has received pre-dose HD) Following a single ruxolitinib dose of 25 mg in patients with varying degrees of hepatic impairment

2012 European Medicines Agency - EPARs

198. Control of pain in adults with cancer

care. 10 psychological distress has been defined by the National Comprehensive Cancer Network as “..a multifactorial unpleasant emotional experience of a psychological (cognitive, behavioural, emotional) social and/or spiritual nature that may interfere with the ability to cope effectively with cancer, its physical symptoms and its treatment. Distress extends along a continuum, ranging from common, normal feelings of vulnerability, sadness and fears to problems that can become disabling (...) patients try to make sense of their experience of pain and to come to terms with a life threatening illness, in the context of their belief system (including specific faith based frameworks). Other studies have dealt with cancer and pain and its impact on how people see themselves, their experiences, and place in the world. One study of elderly hospice patients found that psychological and social pain were identified as worse than physical pain and concluded that professionals should be educated about

2008 SIGN

199. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders

with insomnia perform more poorly on complex cognitive tasks, an e?ect which normalizes following cognitivebehaviouraltherapy(CBT)intervention. Thereisanincreasedriskofsubsequentdepressionandanx- ietydisorderinprimaryinsomnia.Insomniahasbeenassociated with:(1)anincreasedriskofdevelopingsubsequentdepression; (2) an increased duration of established depression; and (3) Difficulty going to Patient complains of sleep problems sleep or staying asleep with impairment of daytime functioning Are sleep habits (...) proposed varying de?- nitions of insomnia that share three key elements (see Diagnostic criteria). They all agree insomnia is a condition of unsatisfactory sleep, either in terms of sleep onset, sleep maintenance or early waking. They also agree that insomnia is a disorder that impairs daytime well-being and subjective abilitiesandfunctioning,andsocanbeconsidereda‘24-hour’ disorder. It is important to recognize that insomnia is a subjective disorder, and its diagnosis is through clinical observations

2010 British Association for Psychopharmacology

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